Building further evidence for the relevance and importance of adopting sustainable solutions for tackling period poverty in Lebanon

With the aim of building momentum on the relevance and importance of producing and distributing locally made reusable sanitary pads to tackle period poverty in Lebanon, this assessment provides further needed evidence on: 1) an estimation of the number of women of reproductive age affected by poverty in Lebanon in need for menstrual hygiene products; 2) a cost-effectiveness analysis for the production and distribution of reusable sanitary pads (versus disposable pads); and 3) current menstrual hygiene practices and acceptability for reusable sanitary pads following the intervention by UNFPA and Akkarouna.
We estimated that around 927,693 women (15-49 years old) currently residing in Lebanon are affected by poverty and are at risk of period poverty (in possible need for menstrual hygiene products). The estimate is based on the most recently available sources, but with caveats in the assessment pointed out.
For the cost-effectiveness analysis, the cost of reusable sanitary pads was compared to the current cost of disposable pads purchased by UNFPA, and the current cost of disposable pads available in the market. Reusable sanitary pads have a life cycle of usage of a minimum of 12 months (13 cycles) so we examined the cost effectiveness of this pad compared to a year-supply of disposable pads. The cost of the reusable sanitary pads distributed by UNFPA is around 18.2 USD. Shifting to reusable sanitary pads (distribution of reusable sanitary pads per woman) in 2 years saves UNFPA 30% of the cost and thus allows UNFPA to reach more women in the long run. Using the market price for disposable sanitary pads, shifting to reusable sanitary pads (distribution of reusable sanitary pads per woman) in 1 year saves women 36% of the cost, allowing women to save money after 9 months of using reusable sanitary pads.
In order to assess current menstrual hygiene practices and acceptability for reusable sanitary pads following the intervention by UNFPA and Akkarouna, an explanatory mixed methods design was adopted where the qualitative data built upon the results of the in-depth analysis of the quantitative data.For the pre-post quantitative assessment, a total of 141 beneficiaries were matched in the pre- and post- survey to investigate the effect of the intervention. Qualitative data was collected through two key informant interviews with two social workers and one Akkarouna staff, and two focus group discussions with a total of 10 vulnerable Lebanese and Syrian refugee women.
The study revealed the changes in menstrual hygiene-related practices among these women following the intervention implemented by Akkarouna, the actual acceptability of reusable sanitary pads, the changes in purchasing practices, and a decrease in the employment of negative coping strategies.
Targeted beneficiaries reported that the main challenge for inadequate access to menstrual hygiene-related products was price inflection. This has led women to opt for lower-quality or cheaper products or to adopt negative coping strategies to alleviate the situation on themselves or their daughters/ sisters. While women aged more than 25-year-old were comfortable using home-made reusable pads, women aged less than 25-year-old preferred disposable sanitary pads. However, following the intervention, there were changes in the usage of sanitary pads. Although young women (under the age of 25) still preferred the use of disposable sanitary pads, they started using reusable sanitary pads as daily pads or during the last one or two days of their period. As for women aged above 25-year-old, while some women switched fully to reusable sanitary pads and felt comfortable during all days of menstruation, most women used disposable pads during the first days of their period or when there is heavy blood flow and switched to reusable sanitary pads during the following days. Additionally, many women reported using reusable sanitary pads as daily pads. Regarding other practices, women reported an improvement in the frequency
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of changing pads, as they used to keep the pad for longer hours to reduce the number of pads used during one cycle and save money.
The concept of reusable sanitary pads was generally well-welcomed and accepted by beneficiaries involved in the surveys and/or FGDs, especially among those who are aged above 25-year-old and among those who already used home-made pads. It was reported that the reusable sanitary pads are comfortable, soft, well-supported by a shield, hygienic, pocket-friendly, and environment-friendly. It was also reported that these pads didn’t cause any discomfort in relation to allergies, infections, itching or bad smell. Still, women reported several challenges such as low absorbent capacity, a low number of distributed pads (especially when women shared the pads with their daughters), washing issues due to water shortage, and drying issues.
With regard to purchasing practices, there was a decrease in purchasing feminine gel and an increase in purchasing shower gel and soap. In fact, the survey results showed that there was a significant decrease in the amount of money spent on menstrual hygiene products. FGDs showed that most women used this amount of money to buy things/ necessities for the house, and very few women used the saved amount to buy menstrual hygiene products (mainly disposable pads) of better quality.
Concerning the potential impact of reusable sanitary pads on overall well-being, survey participants reported a decrease in relying on negative coping strategies related to menstrual hygiene products, a reduction in stress and tension during the menstrual period, and a significant decrease in missing work or school following the intervention.
For the future adoption and use of sanitary pads, targeted beneficiaries reported that they would be willing to use them in the future if the pads were improved as per their recommendations. These included increasing the thickness of pads, increasing the number of pads, increasing the number of awareness sessions (specifically targeting young women), and expanding the outreach program to others. Key informants, on the other hand, suggested that women must first become users of the product so they can be convinced by it and accordingly use it in the future, so they recommended distributing these pads to the largest possible number of women in society. In addition, they highlighted the importance of word of mouth, and how women can affect other women’s opinions after they are happy with the product. As for the challenges, one major challenge reported by most targeted beneficiaries for the future adoption of sanitary pads was cost. Although the price of reusable sanitary pads might be cheaper than disposable pads in the long run, it might be difficult for women to spend such an amount of money in one go. To overcome the barrier of cost, women suggested buying the items step-by-step until they get the needed/ sufficient number of pads and shields for themselves and their daughters.
In light of this assessment’s findings, the following recommendations are put forward:
Advocacy
1. In order to tackle period poverty in Lebanon, UNFPA, other United Nations (UN) agencies, and governmental entities should continue advocating for the mainstreaming of menstrual hygiene management within already existing structures. The Ministry of Public Health (MoPH) should mainstream MHM within the Primary Health Care package (as part of the Sexual and Reproductive Health package, and the personal hygiene service package). The Ministry of Social Affairs (MoSA) can further mainstream MHM within its protection package in the social development centers. The Ministry of Education and Higher Education (MEHE) should incorporate to a greater extent MHM in schools, mainly by updating the curricula to include MHM as well as including it in extra-
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curricular activities. The Ministry of Economy and Trade (MoET) can invest in developing and implementing programs that provide or subsidize the menstrual hygiene needs of marginalized populations. The Ministry of Industry (MoI) and the Lebanese Standards Institution (LIBNOR) can mainstream MHM through developing advocacy activities and enforcing standards for the practices of reusable sanitary pads production, in line with international standards.
2. At the level of the community, relevant entities, NGOs, and civil society should develop well-planned advocacy plans to fight the social stigma around MHM, specifically targeting male-headed households.
3. UNFPA, other relevant entities, and governmental organizations should advocate and promote for the use of reusable sanitary pads in the community, as this is a fundamental girl and woman right. This could be through the implementation of media campaigns (TV, social network, online platforms) or, for example, by assigning representatives in relevant institutions such as PHCs or supermarkets to promote and normalize its use. Showcasing the three cost scenarios (purchasing disposable pads, purchasing reusable sanitary pads and purchasing a mix of both) would be an effective tool.
Coordination
4. UNFPA, other UN agencies, governmental institutions, and local partners, should coordinate to establish a multi-sectoral approach for MHM to ensure optimal integration and implementation of services. In particular, there should be proper planning and collaboration between the private as well as public sectors in the country,
5. UNFPA and other relevant entities such as UN agencies, humanitarian actors, and NGOs producing and/or distributing menstrual hygiene kits should coordinate to further expand their outreach to vulnerable women and girls increasingly affected by period poverty.
6. UNFPA, other relevant entities, and NGOs producing and/or distributing menstrual hygiene kits should further leverage resources and create markets to produce culturally-appropriate reusable sanitary pads based on the availability and prices of raw vs. imported materials.
Knowledge generation
7. UNFPA should engage in the development of a policy brief, explaining the urgency of mainstreaming MHM, especially in the current context, and highlighting the relevance of switching to reusable sanitary pads for health, social integration and women's economic empowerment purposes. The brief would also present the findings of this assessment and other available data, and provide recommendations to use for advocacy and policy change.
8. UNFPA, through implementing partners, should conduct additional pilot studies in different contexts and living conditions (such as informal settlements) in order to assess the actual acceptability of reusable sanitary pads, as well as check for any other concerns or challenges, raised by beneficiaries. This allows for better and more effective production of reusable sanitary pads.
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9. Following this pilot intervention, a SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis should be conducted to better understand the strengths and weaknesses of reusable sanitary pads vis-à-vis disposable pads; the opportunities to improve its positioning, and what may be emerging threats coming from competitors, evolution in consumer preferences and other factors.
10. Local NGOs producing reusable sanitary pads should conduct feasibility studies to expand their production and distribution of these pads to the local market for women to purchase them out -of-pocket and at subsidized cost.
11. UNFPA, other relevant UN agencies, governmental institutions, humanitarian actors, and local organizations should integrate MHM monitoring and evaluation (M&E) into their ongoing M&E sexual and reproductive health and rights outreach and awareness-raising activities to measure the impact of their policies and programmes. UNFPA and other entities should survey the same participants before intervention delivery and post intervention delivery, in order to quantify the impact of interventions.
12. The Ministry of Environment (MoE) along with local and international NGOs, governmental institutions, and humanitarian actors should conduct an environmental impact assessment to compare the effect of disposable vs. reusable sanitary pad production in terms of waste management and energy use.
13. UNFPA and other relevant UN agencies should advocate to assess unmet needs for menstrual hygiene management using nationally representative large-scale surveys.
Capacity development
14. Actors involved in the provision of Water, Sanitation, and Hygiene (WASH) services should implement structural changes to ensure the availability of clean and practical latrines and washing basins as well as maintain proper access to WASH facilities including access to clean and safe water.
15. UNFPA and other relevant entities should build the capacity of local community-based organizations supporting marginalized women, for the production of reusable sanitary pads, as well as other MHM products such as soaps. Such programs would contribute to women's economic empowerment. The Ministry of Industry (MoI) and the Lebanese Standards Institution (LIBNOR) can support small-scale industries in the production of reusable sanitary pads, including compliance with international standards.
16. UNFPA and other relevant entities should create a supportive environment to fight social stigma and build social acceptability for the adoption of reusable sanitary pads. Trusted sources, such as UNFPA implementing partners working on gender-based violence and reproductive health should give these educational sessions, especially that these activities fall within their organizations’ objectives and current activities.
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Service provision
17. UNFPA, and other relevant entities such as UN agencies, should replace the disposable pads included in the dignity kits with reusable sanitary pads as a sustainable cost-effective solution.
18. UNFPA, and other relevant entities including PHCs (whether supported by MoPH, MoSA or other entities) should distribute (for free or at a subsidized cost) reusable sanitary pads to the highest possible number of vulnerable women visiting the centers.
19. Following this assessment, local NGOs producing reusable sanitary pads should be informed about the experiences of women and take into account their recommendations in order to produce improved pads that meet women’s expectations.
MHM education
20. At the level of community, NGOs and civil society should implement nationwide campaigns and awareness sessions that aim towards de-stigmatizing “menstruation” and encouraging the use of reusable sanitary pads. The campaigns should specifically target young women and adolescents which are the most reluctant target groups concerning its usage. For example, as part of the campaigns, the development and dissemination of a short video with a young influencer could be an effective way to target young women and adolescents.
21. UNFPA, and other relevant entities, should develop simple, attractive, and animated educational material on reusable sanitary pads: what they are, their benefits, and how they are used, washed, and dried. The information material should also include, among others, the following messages:
• The difference between home-made and reusable sanitary pads.
• Reusable sanitary pads are for personal use and not to be shared with other family members.
• Reusable sanitary pads need to be washed with cold water and require a limited amount of water.
• Reusable sanitary pads are made from cotton 100%, and accordingly, they don’t cause any health risks related to allergies, infections, irritations, or itching.
• Reusable sanitary pads are more cost-effective than disposable pads in the long run.